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UNIFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this sec on and Sections 1,II,III,IV,and IX below) 430 <br /> [11.NEW PERMIT [13.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ]]]] 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 431 1 DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ _ ? t <br /> BUINESS NAIv,(Same FACILITY or DBA-I mess As) 3 <br /> BUS!TS SITFEDRESS, 103 1 CITY 104 <br /> ci � N' 0C <br /> II.TANK DESCRIPTION <br /> TANK ID#_ ��, / c1 ^1 O 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK 1S 434 <br /> ❑1.A STAND-ALONE TANK <br /> Q 2.ONE IN A COMPARTMENTED UNIT. <br /> edhylete one for ead� tin the unit. <br /> DATEST YS= LLED 435 TANK CLA[ <br /> LL a NUMB F COMPARTMENTS IN THE UNIT air <br /> ✓ �J t <br /> M.TANK USE AND CONTENTS <br /> TANK USE la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL]HSC§25281.5(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED W1b.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ 5.JET FUEL .AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): 44oa <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> C] 11.OTHER NON-PETROLEUMS 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL jr2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> ❑ 90.NONE 13 95.UNKNOWN ❑99.OTIIFR(Specify). 445a <br /> OVERFILL PREVENTION ❑ L AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1.SINGLE-WALLED W.DOUBLE-WALLED ❑99.OTHER 460 <br /> SYSTEM TYPE DL 1.PRESSURE [12.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(x)(3)] 458 <br /> PRIMARY CONTAINMENT 1.STEEL M4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c <br /> PIPTNG/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT L STEEL 3.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 99,OTHER(Specify) 464e <br /> 464el <br /> VENT SECONDARY CONTAINMENT ❑ L STEEL I- FIBERGLASS ❑ 10.RIGIDPLASTIC N 90.NONE ❑ 99.OTHER(Specify) 464f <br /> 46411 <br /> VR PRIMARY CONTAINMENT ® 1.STEEL \4.FIBERGLASS __[T 10.-RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 <br /> 464 l <br /> VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 9 90.NONE ❑ 99.OTHER(Specify) 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 9 90.NONE 464'. <br /> RISER PRIMARY CONTAINMENT JIG 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j <br /> 464'1 <br /> RISER SECONDARY CONTAINMENT 0 L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC pf 90.NONE 99.OTHER(Specify) 464k <br /> 464k1 <br /> FILL COMPONENTS INSTALLED T SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a <br /> CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I cerft that this UST system is compatible with the hazardous substance stored and that the information provided herein is truejAceneate, <br /> and ib full compliaice,witlit legal requirements. <br /> 470. <br /> APPLICANT SIGNATU IR ' 1 DATE / <br /> FiPLICANT NAME(print) fL\ � ` ' / 471 APPLICANT TIT <br /> LJUL ✓ t 472. <br /> �\ O l Iti <br /> 8 2f1 < <br /> UPCF UST-B-1/2 <br /> Rev.(12 <br />